Proximal femur fracture: Difference between revisions

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==Overview==
==Overview==
 
* Imaging
* <span style="line-height: 20px">Imaging</span>
** Consider AP pelvis in addition to standard AP and lateral views to compare to contralateral side
** Consider AP pelvis in addition to standard AP and lateral views to compare to contralateral side
** Consider MRI if strong clinical suspicion but negative xray
** Consider MRI if strong clinical suspicion but negative xray
* Most fractures, including all displaced fx, are treated with ORIF
* Most fractures, including all displaced fx, are treated with ORIF
** Isolated trochanteric fx often does not require surgery�
** Isolated trochanteric fx often does not require surgery
* Skeletal traction is not beneficial�
* Skeletal traction is not beneficial
* Type and cross/screen for pts at higher risk of hemorrhage
* Type and cross/screen for pts at higher risk of hemorrhage
** Age > 75 yrs
** Age > 75 yrs
** Initial hemoglobin < 12
** Initial hemoglobin < 12
** Peritrochanteric fx�
** Peritrochanteric fx
* Adolescent + knee or hip pain = rule-out SCFE�
* Adolescent + knee or hip pain = rule-out SCFE


==Intracapsular==
==Intracapsular==


* ====Femoral Head====
====Femoral Head====
** Usually occurs along with dislocation
* Usually occurs along with dislocation
*** Posterior dislocation - Fracture of inf aspect of femoral head; concomitant sciatic nerve injury
** Posterior dislocation - Fracture of inf aspect of femoral head; concomitant sciatic nerve injury
*** Anterior dislocation - Fracture of anterior femoral head; concomitant vascular injury
** Anterior dislocation - Fracture of anterior femoral head; concomitant vascular injury


* ====Femoral neck====
====Femoral neck====
** Typically minimal bruising (intracapsular)
* Typically minimal bruising (intracapsular)
** If fractured and displaced:
* If fractured and displaced:
*** Externally rotated and shortened
** Externally rotated and shortened
** Garden Classification
* Garden Classification
*** Type 1: Impaction Fx
** Type 1: Impaction Fx
*** Type 2: Nondisplaced Fx�
** Type 2: Nondisplaced Fx
*** Type 3: Displacement of the femoral head
** Type 3: Displacement of the femoral head
*** Type 4: Complete loss of continuity between fragments<span style="line-height: 20px"><br /></span>
** Type 4: Complete loss of continuity between fragments


==Extracapsular==
==Extracapsular==
====Intertrochanteric====
* Typically pain, swelling, ecchymosis
** May lose 1-2L of blood
* Unable to bear weight
* Shortening and external rotation if fracture is significantly displaced
* Types
** Stable - Lesser trochanter is not displaced, no comminution, medial cortices of prox and dist. fragments are aligned
** Unstable - Displacement occurs, comminution is present, or multiple fracture lines exist
====<span style="line-height: 20px">Trochanteric</span>====
* '''Lesser Trochanter'''
** Pain in groin or may present with knee or posterior thigh pain worse with hip flexion and rotation
** Most common in the young (due to forceful contraction of iliopsoas muscle)
*** If occurs in elderly pt with lack of trauma history consider lytic lesion
* '''Greater Trochanter'''
** Hip pain that increases with abduction and tenderness over the greater trochanter
* Imaging
** Lessor trochanter - AP view with the leg in supported external rotation
** Greater trochanter - Standard AP view
* Treatment
** NWB for 3-4 weeks for non-displaced fx
** If displaced (> 1cm) refer to orthopedic surgeon for ORIF


* ====Intertrochanteric====
====Subtrochanteric (including mid-shaft)====
** Typically pain, swelling, ecchymosis
* Occur with severe trauma or in association with pathological bone
*** May lose 1-2L of blood
** Blood loss can be substantial (average loss = 1L)
** Unable to bear weight
* Clinical presentation is similar to intertrochanteric fracture
** Shortening and external rotation if fracture is significantly displaced�
** Types
*** Stable - Lesser trochanter is not displaced, no comminution, medial cortices of prox and dist. fragments are aligned
*** Unstable - Displacement occurs, comminution is present, or multiple fracture lines exist
* ====<span style="line-height: 20px">Trochanteric</span>====
** '''Lesser Trochanter'''
*** Pain in groin or�<span style="line-height: 20px">may present with knee or posterior thigh pain worse with hip flexion and rotation</span>
*** Most common in the young (due to forceful contraction of iliopsoas muscle)
**** If occurs in elderly pt with lack of trauma history consider lytic lesion�<span style="line-height: 20px">�</span><span style="line-height: 20px">�</span>
** '''Greater Trochanter'''
*** Hip pain that increases with abduction and tenderness over the greater trochanter
** Imaging
*** Lessor trochanter - �AP view with the leg in supported external rotation
*** Greater trochanter - Standard AP view
** Treatment<span style="line-height: 20px">�</span>
*** NWB for 3-4 weeks for non-displaced fx
*** If displaced (> 1cm) refer to orthopedic surgeon for ORIF
* ====Subtrochanteric (including mid-shaft)====
** Occur with severe trauma or in association with pathological bone
*** Blood loss can be substantial (average loss = 1L)
** Clinical presentation is similar to intertrochanteric fracture


Source: UpToDate, Harwood-Nuss
==Source==
UpToDate, Harwood-Nuss


[[Category:Ortho]]
[[Category:Ortho]]

Revision as of 21:58, 8 April 2011

Overview

  • Imaging
    • Consider AP pelvis in addition to standard AP and lateral views to compare to contralateral side
    • Consider MRI if strong clinical suspicion but negative xray
  • Most fractures, including all displaced fx, are treated with ORIF
    • Isolated trochanteric fx often does not require surgery
  • Skeletal traction is not beneficial
  • Type and cross/screen for pts at higher risk of hemorrhage
    • Age > 75 yrs
    • Initial hemoglobin < 12
    • Peritrochanteric fx
  • Adolescent + knee or hip pain = rule-out SCFE

Intracapsular

Femoral Head

  • Usually occurs along with dislocation
    • Posterior dislocation - Fracture of inf aspect of femoral head; concomitant sciatic nerve injury
    • Anterior dislocation - Fracture of anterior femoral head; concomitant vascular injury

Femoral neck

  • Typically minimal bruising (intracapsular)
  • If fractured and displaced:
    • Externally rotated and shortened
  • Garden Classification
    • Type 1: Impaction Fx
    • Type 2: Nondisplaced Fx
    • Type 3: Displacement of the femoral head
    • Type 4: Complete loss of continuity between fragments

Extracapsular

Intertrochanteric

  • Typically pain, swelling, ecchymosis
    • May lose 1-2L of blood
  • Unable to bear weight
  • Shortening and external rotation if fracture is significantly displaced
  • Types
    • Stable - Lesser trochanter is not displaced, no comminution, medial cortices of prox and dist. fragments are aligned
    • Unstable - Displacement occurs, comminution is present, or multiple fracture lines exist

Trochanteric

  • Lesser Trochanter
    • Pain in groin or may present with knee or posterior thigh pain worse with hip flexion and rotation
    • Most common in the young (due to forceful contraction of iliopsoas muscle)
      • If occurs in elderly pt with lack of trauma history consider lytic lesion
  • Greater Trochanter
    • Hip pain that increases with abduction and tenderness over the greater trochanter
  • Imaging
    • Lessor trochanter - AP view with the leg in supported external rotation
    • Greater trochanter - Standard AP view
  • Treatment
    • NWB for 3-4 weeks for non-displaced fx
    • If displaced (> 1cm) refer to orthopedic surgeon for ORIF

Subtrochanteric (including mid-shaft)

  • Occur with severe trauma or in association with pathological bone
    • Blood loss can be substantial (average loss = 1L)
  • Clinical presentation is similar to intertrochanteric fracture

Source

UpToDate, Harwood-Nuss

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